Newborn twins given fatal overdose of morphine by UK hospital
NEWBORN twins died after being given more than 10 times the prescribed amount of morphine at a scandal-hit hospital, an inquest has heard.
Alfie and Harry McQuillin were deemed to be in a “good” condition during the first few hours of their lives despite being born 13 weeks early. They were given the drug to stabilise them prior to being moved to a specialist baby unit at another hospital.
However, instead of a prescribed 50mg dose, Alfie was given 600mg of morphine and Harry 850mg.
Their health deteriorated and two days later they died, suffering from lung injuries, bleeding around the brain and other health problems.
An inquest heard that staffing levels on the maternity ward at Stafford Hospital were low and staff were “inexperienced” and “did not understand” correct procedures.
David Field, professor of neo-natal medicine at Leicester University, said: "It seems as clear as one can be from the notes that the babies were quite stable, and then there is evidence of instability in both twins.
"Their heart rates slowed and there were problems with monitoring the level of oxygen in the blood.
"The chances are the babies would have survived if they had not been knocked off course by the morphine, but I can't be sure of that beyond all reasonable doubt."
The inquest heard that the twins' mother, Ami Dean, from Stafford, was rushed to Stafford Hospital in the early hours of October 30th 2010 after she began to bleed.
She gave birth to Alfie at 5.09am and Harry one minute later, and they were both on morphine by 7.10am.
The identical twins were being prepared to be moved from Stafford to a unit better equipped to help premature babies at the University Hospital of North Staffordshire (UHNS), 20 miles away in Stoke, when they were given the overdose.
It was claimed that confusion and uncertainty between staff over the dilution of the drug meant the babies were given too much morphine and oxygen levels in the twins' blood began to drop rapidly.
A quantity of Naloxone, used to combat morphine overdoses, was made up, but was not administered as the twins were stable on a ventilator.
Professor Field said: "Staff were inexperienced and didn't quite understand the dilutive procedure."
The twins were transferred to the UHNS where they died on November 1.The cause of deaths was given as a complication of extreme prematurity.
Doctor Roger Malcolmson, who carried out the post-mortem, said: "From the past history of extremely premature babies, death is likely to have been by natural causes, with an increased risk because they were twins."
After the incident a member of staff was suspended and Maggie Oldham, Chief Operating Officer at of Mid Staffordshire NHS Foundation Trust, launched an internal inquiry.
Police investigated the deaths, but decided there was no criminal case.
The twins' parents, Miss Dean and Phillip McQuillin, said they were "deeply upset and distressed". The coroner Andrew Haigh will record his verdict on May 23.
A 15-month public inquiry into as many as 1,200 unnecessary deaths at Stafford Hospital between 2005 and 2008 has recently finished taking evidence.
Robert Francis QC, the chairman, is due to present his findings to the Health Secretary in October.